骨质疏松与骨质疏松骨折的影像检查

1、骨质疏松及骨质疏松骨折的影像检查,诊断标准之一：骨质疏松性骨折,脆性骨折”是诊断骨质疏松的标准之一。 “脆性骨折”即由于轻微外伤,如从站立或更低的高度跌倒所致的骨折。 Presence of a “fragility” fracture. Fracture due to minimal trauma, such as after fall from standing height or less,3,Osteoporosis affects the entire skeleton,NIH/ORBD (), 2000,Osteoporosis is responsibl

2、e for 1.5 million vertebral and non-vertebral fractures annually Spine, hip, and wrist fractures are most common,Other,Vertebral,Hip,Wrist,骨质疏松性骨折的诊断,综合影像检查： X线平片 CT MRI 骨扫描,诊断骨质疏松性脊柱骨折-重要性,发现脊柱骨折，将来发生骨折的风险增加3-5倍 增加致残率和致死率 适当的治疗可以减少骨折 所以早期发现和诊断非常重要,Ensrud et al. J Am Geriatr Soc 48:241249 Johnell at

3、 al. Osteoporos Int 16(Suppl 2):S3S7,患者常常没有注意，仅25%的椎体骨折有明显临床表现。建议老年人群65岁，常规照胸腰椎X线平片,骨质疏松椎体骨折的诊断-现状,放射科医生认识不足，经常“视而不见”和自我保护 结果是多数脊柱骨折被漏掉,欧洲椎体骨折患病率,1081例社区人群，50岁 X线平片 椎体压缩骨折患病率,安珍，等。中国骨质疏松杂志，2002年，8卷82页,椎体骨折常常被忽视,Gehlbach SH et al, Osteoporos Int, 2000;11:577-582,934 women age 60 and older, hospitaliz

4、ed for various reasons Chest x-rays reviewed for fracture,0,20,40,60,80,100,120,140,Mentioned in,Radiologists Report,52,23,Mentioned in Record,Osteoporosis,17,7,Number of subjects,脊柱骨折的影像检查方法,1，胸腰正侧位X线平片；2，CT扫描的定位像；3，CT矢状重建图像；4，MR检查,脊柱骨折的主要表现是椎体变形,椎体骨折-主要表现为椎体压缩和终板凹陷,女性，64岁,骨疏松骨折：MR鉴别新鲜陈旧,女性，58岁,CT

5、- incidental fractures,Fractures missed in axial CT images sagittal reformations demonstrate fractures,Bauer et al. Osteoporos Int. 2006;17(4):608-15. Mueller et al. Eur Radiol. 2008 Aug;18(8):1696-702,3. CT and fractures,4. Routine CT BMD,2. Indi cati ons,1. QCT technique,3. CT and fractures,4. Rou

6、tine CT BMD,5. New developments,30,CT - incidental fractures,Fractures detected in axial CT images vs. sagittal reformations only 4/28 fractures detected in axial images compared to sagittal reformations# minimum requirements for sagittal reformation 3 mm slice thickness in axial images,Mueller et a

7、l. Eur Radiol. 2008 Aug;18(8):1696-702# Bauer et al. Osteoporos Int. 2006;17(4):608-15,5,Number of fractures,axial,recon,3. CT and fractures,4. Routine CT BMD,2. Indi cati ons,1. QCT technique,3. CT and fractures,4. Routine CT BMD,5. New developments,CT incidental fractures,Scout views Provides info

8、rmation on fracture status up to T8# thus only 10% of fractures (T7-1) are missed,Link et al. Osteoporos Int. 2000;11(4):304-9# Gilsanz et al. Radiology 1994; 190: 678-82# Davis et al. Bone 1999;24:261-264,3. CT and fractures,4. Routine CT BMD,2. Indi cati ons,1. QCT technique,3. CT and fractures,4.

9、 Routine CT BMD,5. New developments,影像鉴别诊断：肿瘤女，57岁，腰疼,腰椎和髋BMD低,影像鉴别诊断：肿瘤女，57岁，腰疼（续,浆细胞性白血病,股骨颈(髋部)骨折-可以很容易,老年妇女，轻微外伤史,女，84岁,股骨颈(髋部)骨折-可以很复杂,当时的CT平扫，一定要做MPR，冠状矢状面重建图像，仔细观察,股骨颈(髋部)骨折-可以很复杂 漏诊后果很严重,关节出现脂肪滴，高度怀疑骨折,骨折线,股骨颈崁插骨折-10天后,十天后,女，66岁，外伤,脂肪滴,骨折线,放射科没有报告骨折，骨科发现骨折，手术治疗,IF right sacrum,R,after long e

10、volution,骶骨机能不全骨折,J.Garcia提供,Colles骨折,68岁妇女,诊断标准之二：骨密度测量,骨密度测量技术是对被测物体骨矿含量、骨密度和体质成份进行无创性定量分析的方法。 目前主要采用的技术有下列几种： 1，双能X线骨密度仪(DXA，pDXA) 2，定量CT(QCT，pQCT) 3，其他骨密度测量技术,Dual energy X-ray absorptiometry (DXA,QCT Technology,QCT was introduced by Harry Genant in 1980s,it is to use clinical CT scanner to meas

11、ure BMD and body composition with QCT system,Mindways QCT system,parts： QA phantom calibrationphantom workstation,QCT protocol,Clinical CT scanner Mindways QCT Supine position,phantom beneath the back CT data are transformed to QCT workstation for BMD,3 D QCT exam,Sag Cor and axial 3 axis adjustment

12、 for location High precision fast Retriavable Data User friendly,QCT vs DXA hip BMD,QCT,DXA,QCT质量控制,欧洲体模,材料和方法,在QCT PRO工作站上测量欧洲腰椎体模，选好测量位置后软件自动生产的感兴趣区（ROI,结 果,BMD测量与常规放射检查的辐射剂量,QCT和DXA-测量不同,QCT: 仅松质骨,DXA: 皮质骨+松质骨,DXA测量脊柱受下列因素影响: Osteoarthritis Aortic calcifications Vertebral fractures or deformities

13、 Scoliosis Obesity,Do people really differ in BMD?QCT vs DXA,骨量的自然演变是一个连续过程不应该有“金标准”需要有一个临界值把高危人群挑出来,Diagnosis of osteoporosis,2007 ISCD，ACR 2008 and 2013. hip as DXA Spine is enough,T值,举例,T值,- 3.0 (SD,病人的BMD 正常成人的平均BMD 正常成人的标准差(SD,北京大学 北京积水潭医院,Elders people 367 Males 154 Female 213 Age 47-92 year o

14、ld（mean age 69.911.0） Mindways QCT，GE Lunar iDXA same time,Comparison QCT vs DXA,QCT is more sensitive in detecting osteoporosis, avoiding misdiagnosis,74 years old ，female back pain,DXA result L2-L4 1.143 g/cm2 T 0.2 Neck 0.701 g/cm2 T -1.9 Total 0.784 g/cm2 T -1.5 diagnosis：osteopenia,QCT results,

15、L3 12.3 mg/cc L4 17.6 mg/cc Average 14.9 mg/cc T -5.9 diagnosis:osteoporosis with fracture,病例,患者，女性，71岁，摔倒后腰痛就诊,TQCT -4.8SD TDXA -1.4SD,有无骨质疏松?螺钉固定是否需要骨水泥,男性，57岁，腰痛，身高180厘米，体重105公斤,DXA骨密度，L1-4 1.01g/cm2, T值-0.6，诊断骨密度正常 QCT 36mg/ml, 诊断骨质疏松 50mg/ml加水泥,有无骨质疏松?螺钉固定是否需要骨水泥,QCT骨密度 120 mg/ml，骨密度正常，不加水泥,男性，59岁，腰痛,髋关节QCT(CTXA,测得髋关节与DXA一样的